PROCESS MAPPING OF INSURANCE DEPARTMENT AND …

www.ijcrt.org © 2021 IJCRT | Volume 9, Issue 8 August 2021 | ISSN: 2320-2882

IJCRT2108210 International Journal of Creative Research Thoughts (IJCRT) www.ijcrt.org b855

PROCESS MAPPING OF INSURANCE

DEPARTMENT AND ANALYSIS OF DENIALS

WITH RESPECT TO DEPARTMENTS

1Dr.Renny Thomas, 2Ashwini Malviya 3Dr.Ankita George 4Tony Thomas 5Gayatri 1Student, 2Assistant manager3Assistant manager 4Assistant manager 5Assistant manager

1Medical Administration, 1IIHMR University, Jaipur, India

ABSTRACT:

BACKGROUND: The primary purpose of the study is to assess the process mapping of the insurance department.

Thereafter the need based assessment and analysis was done according to the specific case. Much of the perceived

negative perception regarding insurance claims denials leads to a loss of 3-5% of net revenue to each hospitals

every year. The current study describes the key causes for revenue losses, insurance claims denials with respect to

department wise and insurance denials and rejection rate with respect to covid and non covid times.

METHOD: The observational descriptive survey type of study was conducted on 176 cashless in patients through

purposive sampling technique for a period of two months

CONCLUSION: The major conclusions derived from the present study are:

1. The turnaround time of the cashless in patients was higher as compared to cash.

2. The department wise delay in cashless treatment was found to be higher in gynecology and obstereitics

3. There was quite less difference in rejection rate between Covid and Non-Covid times.

Keywords: Insurance, denials, process mapping, TPA, cashless delay

1.1 INTRODUCTION

Medical care coverage is a sort of insurance that covers the whole or a piece of the threat of an individual having medical expenses.

Likewise, similarly as with various kinds of insurance is risk among various individuals. By evaluating the overall risk of wellbeing

threat and insurance system costs over the threat pool, a reinforcement plan can foster a standard record structure, for instance, a

month-to-month charge or money charge, to give the money to pay to the clinical benefits decided in the security understanding.

The benefit is constrained by a central affiliation, similar to an organization association, private concern, or not-income driven

substance.

Medical care coverage inclusion in India is a creating segment of India's economy. The Indian healthcare system is one of the

greatest on the planet, with the amount of individuals it concerns: practically 1.3 billion anticipated beneficiaries. The healthcare

business in India has immediately gotten maybe the primary regions in the nation to the extent pay and occupation creation. In

2018, 100,000,000 Indian families (500 million people) don't benefit with healthcare insurance. In 2011, 3.9% of India's GDP was

spent in the Health area. According to the World Health Organization (WHO), this is among the least of the BRICS (Brazil, Russia,

India, China, South Africa) economies. Approaches are open that offer both individual and family cover. Out of this 3.9%, medical

services inclusion addresses 5-10% of utilization, organizations address around 9% while singular go through adds to an astounding

82%.In the year 2016, the NSSO conveyed the report "Key Indicators of Social Consumption in India: Health" considering its 71st

round of audits. The examination finished in the year 2014 found that, more than 80% of Indians are not covered under any medical

services inclusion plan, and simply 18% (government upheld 12%) of the metropolitan people and 14% (government financed 13%)

of the commonplace populace was covered under a insurance protection.

For the money related year 2014-15, Health Insurance charge was ₹20,440.

Medical coverage service in India Launched in 1986, the insurance industry has become basically essentially due to advancement

of economy and general awareness. By 2010, more than 25% of India's populace moved toward some kind of medical services

inclusion. There are independent insurance agencies alongside government supported medical coverage insurance. Health care

coverage in India is a creating part of India's economy.

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1.2 Problem statement of the study:

1. Process Mapping of insurance department

2. Comparative analysis of denials department wise and according to situation in covid and non-covid times.

1.3 Objectives of the present study:

To study the processes of In-patient Insurance claim and discharges in tertiary care facility in a hospital in NCR region of Delhi.

To study Turnaround time of discharge process (of cashless patients)

To study Number of queries from TPA and assess the rejection rate of claims and their major causes,

1.4 Rationale:

Insurance claim process for the cashless patient is very crucial and time consuming for the patients. The hospital faces heavy revenue

loss and dissatisfaction among the discharge patient due to delay in Insurance claim process. This also resulted in delay in discharges

and new admissions. Also, a patient visiting in hospital expects complete care from the time of admission to the time of discharge,

along with, complete medical care, advice and assistance to their claim processing. Although most of these expectations are met,

the patient is still eager to leave the hospital premise at the earliest possible.

1.5 Materials and Methodology:

The type of study was Observational descriptive study. The study period was for a period of 2 months (3 May 2021 to 3 July

2021).The study was conducted in a Tertiary care facility in NCR region in Delhi. The sample Size: 176 cashless In-patients

admitted during study period. The sampling method used was simple purposive sampling. The department time and sample

collection time was from 9:00 am to 5:30 pm. Monday to Saturday.

1.6 Data Collection Method

The data collected was Primary data and other data through Observation

Claim portal- TAT for discharge process of cashless patients

Claim portal & Register -Total number of queries and major causes,

Claim portal & Register -Rejection rate and its major causes

Secondary data: Medical records, Hospital SOPs., IT Department

1.6 PROCESS MAPPING

1.7 Data Analysis:

The analysis was directed to study and check the processes of Inpatients insurance claim and discharges in the hospital. The

Turnaround time was seen from the time discharge told by the doctor till the endorsement from the Insurance organization/TPA

possibly it is acknowledged or dismissed by the organization/TPA. Target population was the discharge Inpatients (Cashless just)

during the observation time frame. To lead, study sample of 176 Cashless Inpatients were taken.

At the point when observational study of turnaround time was done, different explanations behind the deferral in discharge process

was viewed as displayed in Table 1. It was discovered that Delay in file preparation for sending it for insurance company approval

was considered from time when discharge announced by the doctor till it is gotten in the TPA department (Room no. 5). This time

incorporates time taken by the nursing staff to write the consultant visit charges in the activity sheet, putting the patient sticker in

the activity sheet (for billing purpose), time taken by the GDA for transportation of activity sheet to billing desk, time taken to get

ready discharge summary, time taken by consultant and senior resident to finalize the discharge summary and lastly time taken for

doing every one of the corrections proposed by the doctor.




After this file will go to the TPA desk of the hospital from where record will be checked for accessibility of the multitude of required

archives. All the necessary documents/papers will be sent for the last authorization to the insurance agency/TPA.

The Average time needed for document planning (from discharge announced to sending activity sheet for billing) was 30 min (0.5

hr ), Average time needed for TPA company to send approval was 150 min (2hrs 30 min) and average time needed for in discharge

process of the credit only (cashless inpatients) Inpatients was 180 min for example (3 hrs.) as shown (table no.1)

Table 1 : Description of the average turnaround time for various activities

S.no Description Average turnaround time

1 Average time from discharge announced to sending activity sheet 30 Mins

2 Average time required by the TPA company to send approval 150 mins (2 hours 30 mins)

3 Average time required for total discharge process 180 mins (3 hours)

Fig 1: Comparison Between Hospital Ideal Time And Observed Time

To study the variations from these turnaround time, we got to know

Various reasons for this delay in discharge advice placed and final clearance was mentioned in cause-and-effect diagram (Fig.

No.7). Also, various reasons are as follows:

Delay by nursing staff arranging all the documents and investigation reports

Discharge Summary: Typing of discharge summary, finalization by the primary of physician, making corrections in the

discharge summary,

By GDA: Availability of GDA staff, transportation of the file for billing and for discharge summary

Billing generation: Lengthy procedure

Table 2: Description of delayed TPA files from ideal turnaround time

DESCRIPTION TOTAL NO

OF CASES

DELAY 1 HOUR

MORE THAN TAT

TIME

2-3 HOURS MORE

THAN TAT TIME

MORE THAN 3

HOURS OF TAT

TIME

Time required by the TPA

company to send approval

35 11 (31%) 17(48.5%) 7(20.3%)

Time required for total

discharge process

46 23(50%) 9(18%) 14 (30.43%)

Overall delay by the Insurance company/TPA:

The average time taken by the insurance company/TPA is 150min. In 35 cases out of 110 delay was from the company side. In

these 35 cases in 31% cases delay was less than 1 hr, 48.5% cases delay was 2-3 hrs and in 20.11% cases delay was more than 3

hrs which is significantly higher. (Table No: 2/ Fig.3)

There are various reasons for this delay out of which one most important reason is due to number of queries and handling of those

queries, because in handling the queries both company and hospital takes time to resolve it. If there is no any query in the case the

time taken for clearance will be shortened.

Time from dischargeannounced to sending

activity sheet

Time required by theTPA company to send

approval

Time required for totaldischarge process

HOSPITAL IDEAL TAT 15 120 150

AVERAGE TAT 30 150 180

COMPARISON BETWEEN HOSPITAL IDEAL TAT AND OBSERVED TAT

HOSPITAL IDEAL TAT AVERAGE TAT




Figure 3: Overall delay by the company

As given in (Fig-4) these are the departments from which major cashless Inpatients are coming i.e. Gynecology & obstetrics, Gastro-

intestinal surgery, Medicine, neonatology/Pediatric, Urology, Orthosurgery, Cardiology, Neurology etc.

Figure 4: Department wise delay in hospital

The maximum cases are coming from the ortho surgery but the delayed cases are minimum as compared to the other department.

The reason behind less delay in cases of ortho surgery is because most of the TPA queries are promptly solved by the OPD

coordinators of the doctor who thereby help in faster discharge process. If we see Gynecology & Obstetrics also there are major

number of cases but it has maximum delayed cases in discharge. Same with Gl surgery which has topmost number of delayed cases

for discharge. Hence the major focus on Obs & Gyne, Gl surgery, Medicine, Neonatology/Pediatrics, Urology, Orthosurgery can

solve the major problem.

25

15 12 128

19

8 6 7 67 94 5 3 4 3 2 1 1

DELAY DEPARTMENTWISETotal no. of cases Delayed cases




Figure 5: Overall delay by the Company/TPA

Reasons for delay in discharge:

When study this delay in discharge process reasons which are responsible for this day was studied. When it is seen in hospital point

of view hospital cannot reduce time taken by the insurance company by it is possible it hospital will cut short the time taken in

hospital discharge processes. As shown in table no.4 Delay by the hospital only was seen in 9 cases out of 46 cases, delay by the

company/TPA only and not by the hospital was seen in 21 cases out of 46. Delay by the both (The hospital and by the company/TPA)

seen in 16 cases out of 46. (Table no: 3/ Fig.6)

Table 3: Requisite reasons for delay

REQUISTE REASONS No. of cases

Delay by the hospital for discharge (File preparation and mail) 9

Delay by the TPA company for the approval 21

Delay by both (By hospital and company) 16

Total 46

31

48.5

20.3

Overall Delay By The Company/TPA

Delay More than 1 hour 2-3 hours More than 3 hours




Figure 6: Reason for delay in Discharge

1.8. Fish Bone Diagram

9

21

16

Reasons for delay in discharge

Delay by the hospital for discharge Delay by the TPA company for the approval

Delay by both (By hospital and company




Table 4: Table showing description of Queries and Examples of queries

NO TYPE OF QUERIES EXAMPLES

1 Documentation required by the doctor History of alcohol

Name of Drug

Frequency,

Plan of treatment,

Line of treatment,

Need for hospitalisation,

Need for prolonged hospitalisation

Exact duration with etiology

2 Documentation required by patient’s attender Past History and its documentation

3 Documentation required by Patient Pre-hospitalisation papers,

Previous investigation reports,

Valid ID proofs,

MLC copy

4 Documentation required by Hospital Request for admission note

Treatment chart

Vital chart

Doctor progress sheet

Confirmed diagnosis

5 Document requied by management Bill Estimate

Bill break down item wise list

The queries have been come from the insurance company/TPA in 74 cases out of 176. Out of these cases maximum queries has

been asked about for the Documentation by the hospital (32%) and

Investigation reports supporting diagnosis (28% cases).

For documentation required by the doctor (24%), Documentation by the patient (9%),

Figure 7: Various reasons for Queries

24%

18%

33%

2%3%

20%

Queries Reasons and Causes

Investigation reports to support diagnosisDocumentation required by doctorDocumentation required by hospitalMedication chartVital chart




REASONS FOR REJECTIONS/DENIALS

Out of all the data studied from these 176 inpatients, we found that the 11 cases out of 176 got rejected due to various reasons.

The reasons have been enumerated in the table below

In the study objective is to study Rejection rate was 6.25 % and major reasons behind the rejections are: (Fig.8.)

Not covered under their policy (45%).

Limit is exhausted (21%)

Prescribed years not completed (11%)

Hospitalization not justified (7%)

Discrepancy in medical documentation (14%)

Figure 8: Reason for rejection

1.9 Final Suggestions

To initiate more for planned discharges: If specialists can enter" Tentative discharges or expected discharges" request in any event

24hrs before discharge. This way guarantee measure would be started before and along these lines finish simpler. Additionally,

providing discharge request before 9:00 am on the day of discharge would likewise be valuable.

In the event that we give the significant spotlight on department like Obstetrics and gynecology, Gl medical procedure. Medication.

Urology, neonatology/paediatrics, Orthosurgery can tackle almost 80% issue of the delay in discharges.

Likewise, by closing all TPA queries earlier will help almost 41% of the issues to be resolved sooner.

2.0 Conclusion:

Delay caused in bringing the file to Mediclaim department is because of lack of coordination between nurse station and

ward boys.

Delay in completion of discharge summary is due to lack of updating of patient status information on a regular basis.

Delay in making final bill is because of following reasons :

Complexity of billing procedure.

File not cleared in advance by ward for refunding of medicine for expected discharge patients.

Delay in sending file to TPA is because of the following:

Technical issues - unexpected system T A website crash.

Files have to be cross examined several times by medical officer before sending to ΤPΑ

21%

45%

11%

9%

14%

REJECTIONS/DENIALS REASONS

Limit is exhausted Not covered under their policy

Prescribed years not completed Hospitalisation not justified

Discrepancy in medical documentation




2.2 Recommendations For Further Study

Implementation of pharmacy where medication is delivered to the patient’s room.

Preparation of Tentative discharges summary.

Improve the communication between doctors, nurse, floor managers & patients.

Special training should be given to the staff (Training of ANM staff as discharge lounge staff)

Enhancing the coordination between the all the departments

All the activity sheet should not be sent together at the peak time.

ACKNOWLEDGMENT

The investigators thank all the HOD’S, participants for their cooperation and participation during study.

Conflict Of Interest: No any significant conflict of interest.

Source Of Funding: No separate funding was provided for this research study.

REFERENCES

[1] Waymack PM. Light at the end of the tunnel for denials management. Healthc Financ Manage. 2004;58(8):56-66

[2] Burns W, Harmon A. Reducing administrative write-offs through improved denial management. Healthc Financ Manage. 2016;

70(7):30-34

[3] Harris D, Cibenko A, Johnston S, Kline LJ, Silveria R. Straight talk: new approaches in healthcare. Are you in denial over your

denials? Enhance your revenues with denial management. Modern Healthc. 2002;32(47):31-34.


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